(Disclaimer: This article is for general use only, and the following information has been processed to protect patient privacy)
Abstract: A 28-year-old patient, Xiao Wang, presented to our outpatient clinic with “swelling of the right lower extremity for six months after trauma”. Ultrasound was performed in the outpatient clinic, suggesting that there was no echo in the posterior part of the right calf, excluding pseudoaneurysm with arteriovenous fistula. After further examination, the diagnosis of arteriovenous fistula was confirmed, and surgery was performed. The postoperative angiogram showed no traffic between the arteries and veins, and the fistula was successfully closed. Six months after the surgery, the swelling disappeared and the CTA did not show any recurrence of arteriovenous fistula, the overlying stent was patent and the blood flow was normal.
Basic information】Male, 28 years old
Disease Type】Arteriovenous fistula
Hospital】Liaoning Provincial People’s Hospital
Date of consultation】November 2020
Treatment plan】Surgical treatment (lower limb arteriogram, arteriovenous fistula overlay stent isolation)
Treatment Period】7 days of hospitalization and regular review
Results】No traffic between arteries and veins, fistula successfully closed, symptoms relieved
I. Initial consultation
In November 2020, Wang came to the department with “swelling of the right lower limb after trauma for six months” and reported that he had undergone local debridement for trauma to the right lower limb six months ago and found swelling of the right lower limb when he left bed, which was obvious after prolonged standing and exertion. The symptoms recurred. Ultrasound was performed in an outside hospital, suggesting: venous thrombosis of the right lower limb. Since the disease, he was in good mental condition, normal diet and sleep, and normal bowel movement. On examination, the skin color of the right lower limb was normal, the skin temperature was slightly high, tremor could be palpated in the popliteal fossa, anterior tibial finger indentation (+), gastrocnemius grip pain (-), femoral artery pulsation could be detected, popliteal artery, dorsalis pedis and posterior tibial artery pulsation were unclear, and motor sensation was still acceptable. He came to our hospital for outpatient review of the ultrasound: no echo in the posterior right calf, not excluding pseudoaneurysm with arteriovenous fistula. Therefore, he was admitted to the hospital. After admission, the diagnosis of arteriovenous fistula was clarified by further improvement of relevant examinations. In order to determine the location and number of fistulas, CTA of both lower limb arteries was performed, which showed that the popliteal vein was dilated in a circular shape and locally fused with the popliteal artery, and collateral vessels were established around it.
II. Treatment history
Because of his youth, obvious swelling and traumatic arteriovenous fistula with a single number of fistulae, surgery was considered to be the best treatment. After detailed communication with Wang about his condition and treatment plan, he agreed to surgical treatment and underwent arteriography of the lower extremity under local anesthesia and arteriovenous fistula overlay stent isolation. The postoperative angiogram showed that there was no traffic between the arteries and veins and the fistula was successfully closed. The postoperative observation period was 3 days, and the surgical puncture site healed well with no obvious complications, so the patient was discharged successfully, and Wang was asked to come back to the hospital for a review six months before discharge.
III. Treatment effect
The postoperative angiogram showed that the arteriovenous fistula was completely blocked and the venous shadow disappeared in the arteriogram. At the same time, the postoperative swelling gradually relieved, the vascular tremor in the popliteal fossa disappeared, and the skin temperature and skin color gradually returned to normal. At the time of discharge, the swelling symptoms were significantly relieved compared with those before the operation, and the puncture site healed well without complications such as pseudoaneurysm. Six months later, Xiao Wang’s limb recovered well, the swelling disappeared completely, the skin temperature and color were normal, and the CTA of the arterial stent showed smooth blood flow and no arteriovenous fistula formation.
IV. Notes
We are glad that Xiao Wang recovered well after the surgical treatment. After the overlapping stent isolation of arteriovenous fistula, it is necessary to take antiplatelet drugs for at least 1 year, and it is recommended to use them under the guidance of the doctor and avoid stopping them by oneself. After surgery, pay attention to the appearance of skin bleeding spots and other phenomena, and if they occur, seek prompt medical attention. Since there is a risk of restenosis occlusion after overlapping stenting, it is recommended that Xiao Wang should review angiography or CT at least once every six months, and if there is intra-stent thrombosis and intra-stent re-occlusion should be treated promptly. In terms of diet, pay attention to low salt and low fat, as light as possible, and absolutely quit smoking and alcohol; in life, pay attention to rest, elevate the affected limb when resting, and wear medical compression stockings if there is clearly no arterial stenosis or occlusion.
V. Personal insight
Arteriovenous fistula is an abnormal traffic between arteries and veins, generally congenital arteriovenous fistula has many openings and is difficult to deal with and cure. Acquired arteriovenous fistulas are more common with traumatic arteriovenous fistulas, which are mostly single or limited in number and location, and can be considered for endovenous treatment. Clinically, a laminated stent is often used to isolate the arteriovenous fistula and seal the fistula. This approach is a lower risk, faster recovery, and less invasive option for most patients, but congenital arteriovenous fistulas should be carefully evaluated preoperatively to avoid surgical failure due to incomplete sealing of the fistula even after stenting.